Pembroke Lodge

Registration details

The location ID for Pembroke Lodge is 1-676304226.

CQC register Pembroke Lodge to carry out these legally regulated activities. Contact us if you think Pembroke Lodge is operating services not listed here.

Type of service

• Residential homes

Service specialism

• Caring for adults over 65 yrs
• Dementia
• Mental health conditions
• Physical disabilities
• Sensory impairments

Local authority

Reading

Monitored services

CQC register Pembroke Lodge to carry out the following legally regulated services here:

Accommodation for persons who require nursing or personal care

Mr Kingsley Samuel Dhinakar is responsible for these services.

Mr Rasheed Ahamed Mohammed Meeran is the registered manager for these services at this location.

Condition of this registration relating to carrying out this regulated activity

The Registered Provider must within seven days of this condition taking effect ensure that all service users’ care needs are reviewed and assessed, and a copy of this review be sent to the Care Quality Commission each first Monday of every month, identifying any shortfalls and the actions taken in response. The review must:
a. Identify risks associated with service users’ care needs including but not limited to falls risks, dementia care, challenging behaviours, choking risks, infection prevention control, PEEPs assessments and evacuation plans.
b. Update care plans and risk assessments to include personalised care needs. These need to include, but not limited to, risks in relation to living with dementia, dietary needs, challenging behaviours, consent, evacuation plans and falls.
c. Ensure escalation to appropriate medical professionals takes place as necessary which should include utilising specialist advice from a multidisciplinary professional team to assess and mitigate the risks relating to behaviours that are associated with people living with dementia and other health conditions.
d. Identify where care plans, risk assessments and health monitoring assessments are missing for medical conditions and put these in place immediately.
e. Ensure service users have personalised care plans and risk assessments in place detailing what support staff need to provide to meet their individualised needs and risks, including dietary needs.
f. Ensure service users are supported to avoid social isolation; support people to follow interests and to take part in activities that are socially and where appropriate, culturally relevant to them and be involved in decisions about their care.
g. Include a full review of all service users’ medicines.

The Registered Provider must within seven days of this condition taking effect, and for each first Monday of every month thereafter, ensure sufficient levels of staff are always deployed to meet the needs of service users in a safe and personalised manner at Pembroke Lodge. The Registered Provider must ensure staffing levels have been reviewed and met using a staff dependency tool. The Registered Provider must supply the Care Quality Commission with details of any actions taken in response to identified shortfalls. The Registered Provider must supply the Care Quality Commission with staff rotas to demonstrate that each shift has been staffed as assessed. The Registered Provider must provide a report to the Care Quality Commission following such review on every first Monday of every month.

The Registered Provider must within seven days of this condition taking effect, and for each first Monday of every month thereafter, ensure that all staff are suitably competent and trained to assess, plan, and manage risks including the administration/management of medicines and behaviours that are associated with dementia for the role they are to undertake. The Registered Provider must provide a report to the Care Quality Commission following such review on every first Monday of every month.

The Registered Provider must submit to the Care Quality Commission written evidence within 28 days of this condition coming into effect of how they intend to support service users to avoid social isolation; support service users to follow interests and to take part in activities that are socially and where appropriate, culturally relevant to them and be involved in decisions about their care.

The Registered Provider must within 28 days of this condition taking effect, undertake a full review and evaluation of their quality assurance systems to ensure effective systems are in place at Pembroke Lodge. As part of the review and evaluation consideration must be made to the following:
a) The quality assurance process is fit for purpose and includes governance and oversight of incidents and accidents.
b) Assessment, evaluation and evidence of risk assessments to meet the needs of the service users.
c) Audits in relation to building maintenance and decoration at Pembroke Lodge.
The Registered Provider must provide a written report to the Care Quality Commission within 28 days of this condition taking effect and on each first Monday of every month thereafter. The report must include a summary of reviews/ audits that have taken place at Pembroke Lodge to include when and by whom these reviews/ audits were undertaken. These reviews/ audits must include a summary of the findings of each review/ audit undertaken, a summary of what action you have taken because of any review/ audit, including the actions that have been taken if any errors or omissions are found and how risks are to be mitigated as much as possible.

Terms of this registration relating to carrying out this regulated activity

The registered provider must not provide nursing care under accommodation for persons who require personal or nursing care at Pembroke Lodge.

The registered provider must only accommodate a maximum of 20 service users at Pembroke Lodge.